Violence Intervention Advocacy Program Research

Exposure to Neighborhood Racialized Economic Segregation and Reinjury and Violence Perpetration Among Survivors of Violent Injuries

Authors: Elizabeth C. Pino, PhD; Sara F. Jacoby, PhD, MPH; Elizabeth Dugan, MSW, LICSW; Jonathan Jay, DrPH, JD

Structured Abstract: 
Importance: Much is unknown about how individual and neighborhood factors converge in the association with risk for violent reinjury and violence perpetration.
Objectives: To investigate the association of exposure to neighborhood racialized economic segregation with reinjury and use of violence against others among survivors of violent penetrating injury.
Design, Setting, and Participants: This retrospective cohort study was performed using data obtained from hospital, police, and state vital records. The study was performed at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. The cohort included all patients treated for a nonfatal violent penetrating injury from 2013 to 2018. Patients with no Boston metropolitan area home address were excluded. Individuals were followed up through 2021. Data were analyzed from February to August 2022.
Exposure: American Community Survey data were used to measure neighborhood deprivation using the racialized economic Index of Concentration at the Extremes (ICE) for patient residential address upon hospital discharge. ICE was measured on a scale from −1 (most deprived) to 1 (most privileged).
Main Outcomes and Measures: Primary outcomes were violent reinjury and police-reported perpetration of violence within 3 years of an index injury.
Results: Of 1843 survivors of violence (median [IQR] age, 27 [22-37] years; 1557 men [84.5%]; 351 Hispanic [19.5%], 1271 non-Hispanic Black [70.5%], and 149 non-Hispanic White [8.3%] among 1804 patients with race and ethnicity data), the cohort was skewed toward residing in neighborhoods with higher racialized economic segregation (median [IQR] ICE = −0.15 [−0.22 to 0.07]) compared with the state overall (ICE = 0.27). There were police encounters for violence perpetration among 161 individuals (8.7%) and violent reinjuries among 214 individuals (11.6%) within 3 years after surviving a violent penetrating injury. For each 0.1-unit increase in neighborhood deprivation, there was a 13% (hazard ratio [HR], 1.13; 95% CI, 1.03 to 1.25; P = .01) increase in risk of violence perpetration but no difference in risk for violent reinjury (HR, 1.03; 95% CI, 0.96 to 1.11; P = .38). The greatest occurrence for each outcome was within the first year after index injury; for example, incidents of violence perpetration occurred among 48 of 614 patients (7.8%) at year 1 vs 10 of 542 patients (1.8%) at year 3 in tertile 3 of neighborhood deprivation.
Conclusions and Relevance: This study found that living in a more economically deprived and socially marginalized area was associated with increased risk of using violence against others. The finding suggests that interventions may need to include investments in neighborhoods with the highest levels of violence to help reduce downstream transmission of violence.
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Trends in Violent Penetrating Injuries During the First Year of the COVID-19 Pandemic

Authors: Elizabeth C. Pino, PhD; Erika Gebo, PhD; Elizabeth Dugan, MSW, LICSW; Jonathan Jay, DrPH, JD

Structured Abstract: 
Importance: Public health measures instituted to reduce the spread of COVID-19 led to severe disruptions to the structure of daily life, and the resultant social and financial impact may have contributed to an increase in violence.
Objective: To examine the trends in violent penetrating injuries during the first COVID-19 pandemic year compared with previous years.
Design, Setting, and Participants: This retrospective cross-sectional study was performed to compare the prevalence of violent penetrating injuries during the first COVID-19 pandemic year, March 2020 to February 2021, with the previous 5 years, March 2015 to February 2020. This study was performed among all patients with a violent penetrating injury presenting at Boston Medical Center, an urban, level I trauma center that is the largest safety-net hospital and busiest trauma center in New England. Data were analyzed from January 4 to November 29, 2021.
Main Outcomes and Measures: The primary outcomes were the incidence and timing of emergency department presentation for violent penetrating injuries during the first year of the COVID-19 pandemic compared with the previous 5 years. Patient demographics and injury characteristics were also assessed.
Results: A total of 2383 patients (median [IQR] age, 29.5 [23.4-39.3] years; 2032 [85.4%] men and 351 [14.6%] women) presenting for a violent penetrating injury were evaluated, including 1567 Black patients (65.7%), 448 Hispanic patients (18.8%), and 210 White patients (8.8%). There was an increase in injuries during the first pandemic year compared with the previous 5 years, with an increase in shootings (mean [SD], 0.61 [0.89] injuries per day vs 0.46 [0.76] injuries per day; P = .002) but not stabbings (mean [SD], 0.60 [0.79] injuries per day vs 0.60 [0.82] injuries per day; P = .78). This surge in firearm violence began while Massachusetts was still under a stay-at-home advisory and before large-scale racial justice protests began. Patients presenting with violent penetrating injuries in the pandemic surge months (April -October 2020) compared with the same period in previous years were disproportionately male (153 patients [93.3%] vs 510 patients [87.6%]; P = .04), unemployed (70 patients [57.4%] vs 221 patients [46.6%]; P = .03), and Hispanic (40 patients [26.0%] vs 99 patients [17.9%]; P = .009), with a concurrent decrease in White patients (0 patients vs 26 patients [4.7%]), and were more likely to have no previous history of violent penetrating injury (146 patients [89.0%] vs 471 patients [80.9%]; P = .02).
Conclusions and Relevance: These findings suggest that unprecedented measures implemented to mitigate the spread of COVID-19 were associated with an increase in gun violence. As the pandemic abates, efforts at community violence prevention and intervention must be redoubled to defend communities against the epidemic of violence. 
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Racial and Ethnic Disparities in Violent Penetrating Injuries and Long-Term Adverse Outcomes

Authors: Conor M. Nistler, MSW, LCSW; Thea L. James, MD; Elizabeth Dugan, MSW, LICSW; Elizabeth C. Pino, PhD

Abstract: Violent injury is known to be a chronic, recurrent issue, with high rates of recidivism following initial injury. While the burden of violence is disproportionately felt among young Black men and in communities of color, examination of distinct risk factors and long-term outcomes for other racial and ethnic groups could lead to improved violence intervention strategies. In this study, we examined the risk of violent penetrating injury and long-term adverse outcomes by race and ethnicity. This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a violent penetrating injury between 2006 and 2016. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (95%CI) for the risk of all-cause mortality and violent re-injury at one and 3 years after surviving a penetrating injury. 
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Mechanism of Penetrating Injury Mediates the Risk of Long-Term Adverse Outcomes for Survivors of Violent Trauma

Authors: Elizabeth C. Pino, PhD; Francesca Fontin, MPH; Thea L. James, MD; Elizabeth Dugan, MSW, LICSW

Structured Abstract: 
Background: While hospital-based violence intervention programs are primarily designed to aid youth victims of gun violence at high risk for reinjury, the root causes and complex outcomes of community violence are varied. In this study, we examined the risk factors for violent penetrating injury and how the risk of adverse outcomes for survivors differs by injury type (stabbing vs. gunshot wound).
Methods: This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a penetrating injury due to community violence between 2006 and 2016. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95%CIs) for the risk of all-cause mortality and violent reinjury within 3 years after surviving a penetrating injury.
Results: Of the 4,280 survivors of the initial violent penetrating injury, there were 88 deaths (2.1%) and 568 violent reinjuries (13.3%) within 3 years. Compared with gunshot wound victims, stab wound victims were 31% less likely to be reinjured with a gunshot wound (HR, 0.69; 95% CI, 0.51-0.93), 72% more likely to be reinjured with a stab wound (HR, 1.72; 95% CI, 1.21-2.43), and 49% more likely to be reinjured by assault (HR, 1.49; 95% CI, 1.14-1.94). While survivors of stabbing and firearm injuries were equally at risk for 3-year all-cause mortality, stab wound victims were 3.75 times more likely to die by a drug/alcohol overdose (HR, 3.75; 95% CI, 1.11-20.65).
Conclusion: Patients surviving a stab wound have a significantly higher risk of violent reinjury by stabbing or assault, and risk of death by drug/alcohol overdose. Hospital-based violence intervention programs with similar patient populations should explore options to expand partnerships with drug treatment programs. These results illustrate two distinct populations of victims of violence—gunshot victims and stabbing/assault victims―with separate risk factors and outcomes, mediated by substance use disorder. 
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Implementation of a Novel Home Visiting Nurse Pilot Program for Victims of Violent Penetrating Injury

Authors: Elizabeth C. Pino, PhD; Francesca Fontin, MPH; Elizabeth Dugan, MSW, LICSW

Structured Abstract: 
Background: Survivors of violent injuries are at risk for readmission, rehospitalization, and reinjury. In 2017, a novel home visiting nurse pilot program was implemented within a hospital-based violence intervention program (HVIP) to address disparities in care and combat the limited health care literacy and access, and the general mistrust of health care institutions among much of this population.
Objective: The purpose of this study was to review the design and implementation of the home visiting nurse component of the HVIP and to report the demographics, clinical characteristics, home care needs, and short-term health outcomes of the pilot sample.
Methods: This retrospective study was performed using a cohort of patients presenting to the emergency department at an urban, Level I trauma center for a violent penetrating injury between 2017 and 2018. The χ² and Wilcoxon rank sum tests were used to compare patient demographics and injury characteristics. Cox proportional hazards regression models were used to estimate health outcomes. 
Results: Of the 742 victims of violence included in this analysis, the 57 patients enrolled in the home visiting nurse pilot program were more likely to have severe gunshot wounds (68.4% vs. 40.3%, p < .001) requiring hospitalization (80.7% vs. 53.3%, p < .001), with 3.5% requiring rehospitalization within 90 days. The primary interventions provided by the home visiting nurse involved medical navigation and education, wound care, and consultation, underscoring the critical importance of health literacy and outreach for this vulnerable population.
Conclusion: The nurse–advocate partnership provides the foundation for this novel program to aid a marginalized population in overcoming health inequities. 
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Pediatric Firearm Injuries and Fatalities — Chapter 11: Violence Intervention Advocacy Program and Community Interventions

Authors: Elizabeth C. Pino, PhD; Francesca Fontin, MPH; and Elizabeth Dugan, MSW, LICSW

Abstract: In 2006, after a resurgence of youth violence in the City of Boston, MA, the Violence Intervention Advocacy Program (VIAP) was established at Boston Medical Center (BMC). Like other hospital-based violence intervention programs, BMC’s VIAP is an emergency department (ED)-centered program taking advantage of the short window after a traumatic injury when the victim of violence is at a crossroads and may be more amenable to an intervention. The VIAP trains staff as peer advocates for victims of violence and their family, aiding in the physical and emotional recovery from injury. These advocates partner with hospital and community groups to deliver a broad spectrum of care and offer local and national trainings in peer advocacy and trauma-informed care. The VIAP presents the case of an 18-year-old male who suffered a gunshot wound to the head resulting in complete loss of vision. This case highlights the importance of family support, trauma-informed care, patient advocacy, and addressing social determinants of health in the recovery of young victims of firearm injury. Pediatric clients, defined here as 24 years old or younger, comprise 44% of the violent penetrating injuries presenting to the BMC ED over the history of the VIAP, and 54% of these pediatric injuries were gunshot wounds. The 12-year downward trend in the overall number of violent penetrating injuries at BMC appears to exclusively be the result of a dramatic decrease in the number of pediatric injuries, suggesting that youth violence is preventable and that violence intervention programs save lives and reduce reinjury.
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Gender Differences in Violent Penetrating Injuries and Long-Term Adverse Outcomes

Authors: Elizabeth C. Pino, PhD; Francesca Fontin, MPH; Thea L. James, MD; Emily F. Rothman, ScD; Elizabeth Dugan, MSW, LICSW

Abstract: Violent injury is known to be a chronic, recurrent issue, with high rates of recidivism in the 5 years following initial injury. Much of the strategy behind violence intervention programs, who are tasked with reducing recidivism, is directed toward young men, while there has been little research into the unique risk factors or long-term outcomes for female victims of violence. The aim of this study was to examine the risk of violent injury and long-term adverse outcomes by gender. This retrospective study was performed using a cohort of 4337 patients presenting to the Boston Medical Center emergency department for a violent penetrating injury between 2006 and 2016. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the risk of all-cause mortality and violent reinjury at 1 and 3 years after surviving a penetrating injury. There were 88 deaths (2.1%) and 568 violent reinjuries (13.2%) within 3 years after surviving the initial penetrating injury. At initial injury presentation, women were more likely to have a preexisting mental health diagnosis and to have been injured as a result of domestic violence. While men had greater than six times the risk of 3-year mortality compared to women (HR = 6.36, 95% CI = 1.56-25.83), both genders were equally at risk for violent reinjury (HR=1.23, 95% CI=0.95-1.59). Men were more likely to have a stab wound (HR=2.68, 95% CI=1.41-5.10) or gunshot wound (HR = 7.96, 95% CI = 2.95–21.48) reinjury, while women were more likely to have an assault (HR = 1.52, 95% CI = 1.13–2.04) or domestic violence (HR = 2.96, 95% CI = 1.43-6.12) reinjury. Compared to men, the risk of violent reinjury was significantly increased for women with a history of substance use disorders (p-interaction = 0.009). These results suggest a unique trifecta of risks for women—substance use, mental illness, and domestic violence—and underscore the critical role of violence intervention programs in addressing these risks to mitigate violent injury recidivism. 
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Boston Violence Intervention Advocacy Program: Challenges and Opportunities for Client Engagement and Goal Achievement 

Authors: Elizabeth C. Pino, PhD; Francesca Fontin, MPH; Thea L. James, MD; Elizabeth Dugan, MSW, LICSW

Structured Abstract: 
Objectives: A better understanding of the factors affecting client engagement in hospital-based violence intervention programs (HVIPs), and which types of client needs prove most challenging to achieve, may be of key importance in developing novel, targeted strategies to violence intervention. In this study, we examined the demographics and injury characteristics of violently injured patients by their level of engagement with the Boston Violence Intervention Advocacy Program (VIAP) and determined the degree of client goal achievement through VIAP client services.
Methods: This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a violent penetrating injury due to community violence between 2013 and 2018. Data on client demographics, injury characteristics, and client needs were collected from the VIAP data repository. Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals to assess the difference in hazards of client goal achievement by need type.
Results: Of the 2,243 victims of violent injury, 839 (37.4%) patients engaged with VIAP. Significant predictors of client engagement include younger age, Black race, permanent home, existing mental health diagnosis, gunshot wound, and more severe injuries. Conversely, older age, homelessness, substance use, stab wound, and less severe injuries predicted refusal of VIAP services. For clients who chose to engage with VIAP, needs related to education (HR = 0.47, 95% CI = 0.38 to 0.58), employment (HR = 0.66, 95% CI = 0.57 to 0.77), and housing (HR = 0.76, 95% CI = 0.68 to 0.86) were significantly less likely to be achieved compared to basic needs.
Conclusions: This study demonstrates that VIAP is effectively engaging the client population that HVIPs have been designed to support. HVIPs should consider novel strategies to engage vulnerable populations not typically targeted by intervention programs. These results speak to the difficulties of program attrition and the complexities of altering the life course for victims of violence.
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Compassion Satisfaction and Compassion Fatigue among Violence Intervention Caseworkers 

Authors: Francesca M. B. Fontin; Elizabeth C. Pino; James Hang; Elizabeth Dugan

Abstract: Violence intervention programs aim to help clients overcome trauma, but, due to the demands of their profession, caseworkers are at risk for experiencing low compassion satisfaction and high compassion fatigue. This cross-sectional study sought to describe the prevalence of compassion satisfaction and compassion fatigue (burnout and secondary traumatic stress [STS]) among 93 caseworkers. Participants completed the Professional Quality of Life Survey at a conference for a national network of hospital-based violence intervention programs in September 2018. Results displayed high compassion satisfaction across demographic groups, while participants significantly differed in compassion fatigue by years of experience and workplace setting. Caseworkers who had been working in their profession for 6-10 years experienced higher levels of burnout than those working fewer years (p = 0.02). Further, caseworkers employed in a single program setting experienced significantly lower levels of STS than those who work in both a community and hospital setting (p = 0.01). This analysis stands in contrast to previous studies showing higher levels of compassion fatigue in younger, and less experienced healthcare workers. Further studies are warranted to determine how the prevalence of compassion fatigue in victim advocates compares to those of other healthcare providers and which interventions can best promote compassion satisfaction.
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Boston Violence Intervention Advocacy Program: A Qualitative Study of Client Experiences and Perceived Effect

Authors: Thea L. James, MD; Salma Bibi, MPH; Breanne K. Langlois, MPH; Elizabeth Dugan, MSW, LICSW; Patricia M. Mitchell, RN

Structured Abstract: 
Objectives: This study intended to explore clients’ experiences and provide a contextual basis for understanding their perceptions of the effectiveness of the Boston Medical Center (BMC) Violence Intervention Advocacy Program (VIAP).
Methods: This was an exploratory, qualitative study conducted in an urban, Level I trauma center from July 1, 2011, to February 24, 2012. Emergency department (ED) patients older than 18 years with penetrating trauma, and who were enrolled in the VIAP, were eligible. Two trained, qualitative interviewers who were not part of the VIAP obtained consent and conducted in-depth, semi-structured interviews. Interviews were audiotaped, transcribed, deidentified, coded, and analyzed. Thematic content analysis consistent with grounded theory was used to identify themes related to client experiences with VIAP, life circumstances, challenges to physical and emotional healing postinjury, services provided by VIAP, and perceptions of VIAP’s effectiveness.
Results: Twenty subjects were interviewed. Most were male, African American, and younger than 30 years of age, reflecting the overall program’s clientele. Most subjects perceived their advocates as caring adults in their lives and cited aspects of the peer support model that helped establish trusting relationships. Major challenges to healing were fear and safety, trust, isolation as a coping mechanism, bitterness, and symptoms of posttraumatic stress disorder (PTSD). Every subject noted important services provided by VIAP advocates. Most subjects explicitly stated that they had positive experiences with the VIAP and perceived advocates’ roles as a positive influence, providing client-centered advocacy, education, and support.
Conclusions: This study provides insight into the lives of 20 BMC VIAP clients and contextualizes their unique challenges. Participants described positive, life-changing behaviors on their journey to healing through connections to caring, supportive adults. Information gained from this study will help the VIAP to further support its clients. However, future research is needed to identify best practices for ED-based violence intervention programs and to measure community-wide efficacy in different settings.
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